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Applications Will Be Processed When Submitted Properly Completed.Be Sure ToSign TheApplication. <br /> FOR OFFICE USE., APPLICATION j <br /> _ (For Non-Transferable, Revocable,Suspendable) PUMP&WELL ! <br /> ENVIRONMENTAL HEALTH PERMIT <br /> a <br /> (COMPLETE IN TRIPLICATE) +WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oaquin County Ordinance No. 1862 nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address— O W� City/Town 1 &- - <br /> Owner's Name Phone <br /> - City 1 <br /> i Address <br /> fl Contractor's Name C ' License# � '7 l Business Phone i <br /> Contractor's Address G7 '� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 1:1 PUMP INSTALLATION ❑ PUMP REPAIR <br /> a REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> 2 OOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> [ ❑ DISPOSAL ❑ OTHER Other Information <br /> 1 ❑ GEOPHYSICAL Surface Seal Installed By: <br /> [L PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is Issued, I shall employ persons subject to workman's compensation laws of California." <br /> will c i or a Grou inspection prior to grousing and a final inspection. <br /> Signed Title: .- &r.� _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR QEPA;RT T USE ONLY <br /> PHASE I <br /> i Application Accepted By <br /> Date `' ✓ <br /> Additional Comments: <br /> Phase II Grout Inspection Ph I 1 Inspection <br /> r <br /> Inspection By Date Inspection By Date <br /> Fee IS DUB: 11 ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 &Re eived By January 31 ❑ July 1 &Received By July 31 <br /> REMfT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 , <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No. I IssuaInce Date Mailed oegve <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ;1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />